A young woman was referred to a general surgeon for
consideration of gastric bypass surgery. It was noted in the
referral that the woman had been diagnosed with a psychiatric
condition, and that she was under the care of a private
psychiatrist. It was also noted that she had gained over 40kg since
being on medication for her condition. The woman attended three
preoperative assessments. The surgeon did not contact the woman's
psychiatrist as part of his assessment of her suitability for
surgery.

The woman underwent gastric bypass surgery. By that time, her
weight had increased a further 20kg. Her initial recovery from
surgery was straightforward. She was reviewed by the surgeon six
weeks postoperatively, at which time she was prescribed
multivitamins. Patients who have had gastric bypass surgery are
known to be at risk of vitamin deficiencies because of their
restricted diet, and therefore need to take multivitamins on an
ongoing basis.

Over several weeks, the woman presented at the public hospital
nine times. Her symptoms invariably included abdominal pain,
nausea, and vomiting. A range of investigations were carried out
during the course of her admissions, but the cause of her symptoms
was not identified. For the most part, she was under the care of
the Upper Gastrointestinal service, but a number of other services,
including dietetics, psychiatry, and pain management, were also
involved. The woman was not prescribed multivitamins during her
admissions to the public hospital.

The surgeon was aware of the woman's ongoing problems and her
admissions to the public hospital, and he was in contact with
clinicians there.

On her tenth admission to the public hospital, she complained of
blurry vision and was reviewed by an ophthalmologist, who noted
paralysis of the muscles responsible for eye movement, and a
reduction in visual acuity. A neurology review indicated thiamine
deficiency and a Wernicke's type encephalopathy. The woman's sight
and mobility have been permanently harmed.

It was held that the surgeon did not adequately assess the
woman's suitability for surgery. He failed to obtain a formal
psychiatric or psychological assessment, or consult her
psychiatrist. The surgeon failed to provide services with
reasonable care and skill and, accordingly, breached Right 4(1). He
was criticised for failing to take steps to arrange for the woman
to have an alternative mode of administration of the multivitamins,
and for failing to advise clinicians at the public hospital that he
had prescribed multivitamins.

The woman was not asked whether she was taking multivitamins,
and was not prescribed them during her admissions to the public
hospital until her thiamine deficiency was diagnosed. In addition,
there was a failure by staff at the public hospital to adequately
assess her nutritional status in light of her limited oral intake,
due to ongoing nausea and vomiting. In the circumstances, the
District Health Board failed to provide services with reasonable
care and skill and, accordingly, breached Right 4(1). Other aspects
of the care provided by the DHB were also criticised.